States Respond to COVID-19 Challenges but Also Take Advantage of New Opportunities to Address Long-Standing Issues: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2021 and 2022

Social Determinants of Health

Context

Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age that shape health. Prior to the pandemic, non-health and health sectors have engaged in initiatives to address SDOH. In response to the pandemic, federal legislation was enacted to provide significant new funding to address the pandemic’s health and economic effects including direct support to address food and housing insecurity, stimulus payments to individuals, federal unemployment insurance payments, and expanded child tax credit payments. While measures like these have a direct impact in helping to address SDOH, health programs like Medicaid can also play a supporting role. Although federal Medicaid rules prohibit expenditures for most non-medical services, state Medicaid programs have developed strategies to identify and address enrollee social needs both in managed care and fee-for-service (FFS) delivery systems.¹ CMS released guidance for states about opportunities to use Medicaid and CHIP to address SDOH in January 2021.²

Communities of color have higher rates of underlying health conditions compared to White people and are more likely to be uninsured or report other health care access barriers.³ The COVID-19 pandemic exacerbated already existing health disparities for a broad range of populations, but specifically for people of color.⁴ Multiple analyses of available federal, state, and local data show that people of color are experiencing a disproportionate burden of COVID-19 cases and deaths.⁵ In addition to worse health outcomes, data from the Census Bureau’s Household Pulse Survey show that over the past year, Black and Hispanic adults have fared worse than White adults across nearly all measures of economic and food security.⁶

As the U.S. continues to grapple with the COVID-19 pandemic, the latest KFF COVID-19 Vaccine Monitor finds that more than seven in ten U.S. adults (72%) now report being at least partially vaccinated, with the surge in cases, hospitalizations, and deaths due to the Delta variant being the main motivator for the recently vaccinated.⁷ The largest increases in vaccine uptake between July and September were among Hispanic adults and individuals ages 18-29, and similar shares of adults now report being vaccinated across racial and ethnic groups (71% of White adults, 70% of Black adults, and 73% of Hispanic adults). Large differences in self-reported vaccination rates remain between older and younger adults, individuals with and without college degrees, and those with higher and lower incomes. Adults living in rural areas continue to have lower vaccination rates than those living in urban and suburban areas. Because Medicaid covers over 82 million enrollees, including groups disproportionately at risk of contracting COVID-19, state Medicaid programs and Medicaid managed care organizations (MCOs) (which enroll over two-thirds of all Medicaid beneficiaries)⁸ can be important partners in COVID-19 vaccination efforts.⁹

This section provides information about:

• Initiatives to address social determinants of health;
• Efforts to expand community health worker workforce;
• Initiatives to address disparities in health care by race/ethnicity in Medicaid; and
• COVID-19 vaccine-related MCO initiatives

Findings

Initiatives to address Social Determinants of Health

Social determinants of health include but are not limited to housing, food, education, employment, healthy behaviors, transportation, and personal safety. Addressing social determinants of health is important for improving health and reducing longstanding disparities in health and health care. Although federal Medicaid rules prohibit expenditures for most non-medical services, state Medicaid programs have been developing strategies to identify and address enrollee social needs both within and outside of managed care.¹⁰

The vast majority of responding states that contract with MCOs (33 of 37) reported leveraging MCO contracts to promote strategies to address the social determinants of health in FY 2021 (Figure 5). In this year’s survey, MCO states were asked about MCO contract requirements related to social determinants of health in place in state fiscal year (FY) 2021 or planned for implementation in FY 2022. More than half of responding MCO states reported the following requirements were in place in FY 2021: screening enrollees for behavioral health needs, providing referrals to social services, partnering with community-based organizations (CBOs), and screening enrollees for social needs. About half of responding MCO states reported requiring or planning to require uniform SDOH questions within MCO screening tools. Fewer states reported requiring MCOs to track the outcomes of referrals to social services or requiring MCO community reinvestment (e.g., tied to plan profits or MLR) compared to other strategies; however, a number of states indicated plans to require these activities in FY 2022.

The following are examples of state MCO initiatives related to social determinants of health:

• Arizona’s Whole Person Care Initiative, which was launched in November 2019, seeks to address social risk factors in collaboration with MCOs, community-based organizations, tribal partners, providers, and other external stakeholders. The Whole Person Care Initiative: provides support for transitional housing for certain high-need enrollees (e.g., those experiencing chronic homelessness or transitioning from correctional facilities); leverages existing non-medical transportation services to support member access to community-based services; works to reduce social isolation among Medicaid enrollees using long-term care services; and is partnering with Arizona’s Health Information Exchange to establish a statewide closed-loop referral system.¹¹
• In FY 2021, North Carolina launched a new pilot program, called “Healthy Opportunities Pilots,” to cover non-medical services to address housing instability, transportation insecurity, food insecurity, interpersonal violence, and toxic stress for a limited number of high-need enrollees in managed care plans.¹² Healthy Opportunities “Network Leads” will develop, contract with, and manage the network of human service organizations that will deliver pilot services. MCOs in participating regions will be required to participate and will manage the pilot budget, enrollee eligibility, and authorize pilot services as well as work in collaboration with Network Leads to track pilot services.
• Tennessee plans to procure a closed loop referral system to support MCOs and providers in screening for social needs, making referrals to social services, and tracking follow-up. The system is scheduled to be implemented in 2022.

In addition to initiatives through MCOs, many states have strategies outside of their MCO programs (in FFS programs) to address social determinants of health.¹³ This year’s survey asked all states about non-MCO initiatives in place in FY 2021 or planned for implementation in FY 2022 related to social determinants of health. About half of responding states reported non-MCO initiatives in place in FY 2021 related to screening enrollees for social needs, screening enrollees for behavioral health needs, providing enrollees with referrals to social services, and partnering with CBOs or social service providers. About a quarter of states or fewer reported non-MCO initiatives in place in FY 2021 to employ community health workers, encourage/or require providers to capture SDOH data using ICD-10 Z codes, track the outcomes of referrals, or incorporate uniform SDOH questions within screening tools.

Medicaid Initiatives to Address SDOH in Response to the COVID-19 Pandemic

Over half of responding states reported that the COVID-19 pandemic caused their state to implement, expand, or reform a Medicaid program that addresses enrollees’ social determinants of health. States reported a variety of initiatives; however, the most commonly reported initiatives were related to food/nutrition assistance and/or housing. Notable examples include: Arizona’s Medicaid agency established a partnership with a community provider that has access to the Homeless Management Information System (HMIS).14 HMIS is used to collect data on the provision of housing and services to homeless individuals and families and persons at risk of homelessness.15 The state Medicaid agency obtains weekly reports with Medicaid members found in HMIS who test positive for COVID-19 and have recently accessed homeless services. The state Medicaid agency shares this information with MCOs so that they can conduct outreach to these Medicaid enrollees and provide care management and follow-up services. California expanded its “Whole Person Care” (WPC) pilot program in response to the pandemic.16 The WPC program aims to coordinate care (physical, behavioral, and social services) for high-risk, high-utilizing Medicaid (Medi-Cal) enrollees and increase integration and data sharing among county agencies, health plans, and CBOs. In response to the COVID-19 pandemic, the pilot was expanded to allow participating counties to offer care coordination and other services to Medi-Cal enrollees who contracted COVID-19 or were at-risk of contracting COVID-19. For example, some WPC counties expanded housing services available (frequently for individuals experiencing homelessness) as well as other care management and wrap-around services. The state was able to leverage the WPC pilots and existing community partnerships to quickly mobilize in response to the pandemic to reach the most vulnerable Medi-Cal enrollees.17 North Carolina leveraged the design of its “Healthy Opportunities Pilots” to create a similar program in select counties that funded CHWs to screen and refer individuals who needed to isolate or quarantine due to COVID-19 to medical and non-medical services, and then funded services including non-congregate shelter, home-delivered meals and groceries, COVID-19 relief payments, medication and COVID-19-related supplies, and transportation.18 To support this effort, the NC Department of Health and Human Services braided funds including COVID-19 relief funds, FEMA funds, and state Medicaid funds. Early results from this program showed participating in the program was associated in a 12-15% decrease in COVID-19 positivity rates in counties with the program relative to control counties. Health equity was a major focus of this initiative and over 70% of support services were provided to historically marginalized populations.

efforts to expand community health worker Workforce

More than half of states reported Medicaid workforce initiatives in place in FY 2021 or planned for FY 2022 to expand the number of community health workers in the state. Community Health Workers (CHWs) can play an important role in addressing social determinants of health. CHWs are frontline workers who have close relationships with the communities they serve, allowing them to better liaise and connect community members to healthcare systems.¹⁹ CHW examples include care coordinators, community health educators, outreach and enrollment agents, patient navigators, and peer educators. CHWs can provide support to Medicaid enrollees by facilitating care coordination, providing culturally competent care, and linking enrollees to relevant resources and services.^20,21 CHWs also have played an important role in trying to mitigate the spread of COVID-19.²² Historically, most CHW programs have been run and funded through community health centers and other community-based organizations. This year’s survey asked states to describe any Medicaid workforce initiatives underway in FY 2021 or planned for FY 2022 to expand the number of CHWs. States reported initiatives including:²³

• Adding CHWs as a Medicaid covered service. Five states plan to add CHWs as a Medicaid covered service in FY 2022 (California, Illinois, Louisiana, Nevada, and Wisconsin).
• Adding CHWs as a Medicaid provider type. Four states reported they are establishing or planning to establish CHWs as a Medicaid provider type (Arizona, California, District of Columbia, and Illinois). For example, California is exploring adding CHWs as a provider type through a State Plan Amendment for preventative services in both the fee-for-service and managed care setting.
• Integrating CHWs into case or care management efforts. Two states are incorporating CHWs into case management redesign/care coordination improvement efforts (Colorado and Oregon). Additionally, Oregon passed state legislation that will officially recognize Tribal Traditional Health Workers as a type of CHW.²⁴ CHWs are required to be included as an available service in managed care contracts in Oregon, meaning that Tribal CHWs will become more available for those who need them.²⁵

State Medicaid CHW Workforce Initiative Examples

California, starting on January 1, 2022, will allow their MCOs to begin offering certain “in lieu of” services which they expect will increase the number of CHWs MCOs contract with. California is also exploring the ability to allow community-based organizations to participate in its Medicaid program as an enrolled provider of CHWs. As part of Illinois’ first round of grant funding for its “Healthcare Transformation Collaboratives” program,26 the state will support the work of CHWs and will apply lessons learned within the Medicaid program. The Healthcare Transformation Collaborative, created in January 2021, seeks to fund collaboratives between healthcare providers and community-based organizations to increase access to preventative care, chronic disease management, and obstetrics care, and ultimately improve health outcomes.27 Missouri’s Medicaid agency has a contract with the Missouri Primary Care Association to expand the Community Health Worker Program designed to address social determinants of health, improve patient engagement in preventative care, provide chronic disease management and self-management services, connect patients with community-based services, and reduce potentially avoidable emergency room visits and hospital admissions and readmissions.

initiatives to address disparities in health care by race/ethnicity in Medicaid

Communities of color have higher rates of underlying health conditions compared to White people and are more likely to be uninsured or report other health care access barriers.²⁸ The COVID-19 pandemic exacerbated already existing health disparities for a broad range of populations, but specifically for people of color.²⁹

Three-quarters of responding states reported initiatives in place in FY 2021 or planned for FY 2022 to address disparities in health care by race/ethnicity in Medicaid. We asked states to identify innovative or notable initiatives in this area, and many of the state responses overlapped with initiatives also reported elsewhere on the survey. About half of responding states reported managed care requirements and/or initiatives to address health disparities, including Performance Improvement Projects (PIPs), requirements that MCOs achieve the NCQA Distinction in Multicultural Health Care,³⁰ and pay-for-performance (P4P) initiatives. Nearly half of responding states reported focusing on using data to address health disparities, including by stratifying quality and other measures by race/ethnicity. Many of these states planned to expand or improve data collection to better identify disparities. A few states reported that eligibility or benefit expansions would address health disparities, particularly for pregnant and postpartum women, non-citizens, and justice-involved populations. Many states cited efforts to diversify, support, and/or train workforces to increase cultural competency, including by partnering with community-based organizations.

Twenty states reported initiatives to address disparities in specific health outcomes, including maternal and infant health, behavioral health, and COVID-19 outcomes and vaccination rates (Exhibit 3). For example:

• To address disparate maternal health outcomes for Black women, Connecticut is developing a comprehensive maternity bundled payment that includes obstetrician/nurse midwife services, doulas, community health workers, and breastfeeding support. Pennsylvania reported a P4P maternity care bundled payment arrangement that will reward providers that reduce racial disparities.³¹
• Since FY 2020, Michigan has used capitation withholds to incentivize reductions in racial disparities in behavioral health metrics. California’s value-based payment program directs MCOs to address health disparities by making enhanced payments that target serious mental illness, substance use disorder, and homelessness.
• Several states reported efforts to reduce disparities in COVID-19 vaccination rates. For example, one of Iowa’s MCOs has developed a vaccine outreach program that monitors for low uptake among traditionally underserved member groups (including by race and language).
• Two states cited programs to reduce disparities in diabetes outcomes. Maine is supporting the training of community health workers to provide culturally engaging outreach around diabetes management. In FY 2021, Ohio focused on reducing diabetes disparities through an MCO PIP.

COVID-19 Vaccine-Related MCO Initiatives

Currently, there are three COVID-19 vaccines approved for use in the U.S. States and public health agencies are playing a central role in vaccine distribution and the public health promotion of these vaccines. Because Medicaid covers over 82 million enrollees, including groups disproportionately at risk of contracting COVID-19, state Medicaid programs and Medicaid MCOs can be important partners in COVID-19 vaccination efforts.³²

States report a variety of MCO activities aimed at promoting the take-up of COVID-19 vaccinations. Given that MCOs provide services to over two-thirds of Medicaid enrollees, states were asked to describe any known programs, initiatives, or value-added services newly offered by MCOs to promote take-up of COVID-19 vaccinations.³³  States reported a wide variety of initiatives including: member and provider incentives, member outreach and education (including targeted outreach to high-risk members or areas demonstrating disparities in access or take-up), provider engagement, assistance with vaccination scheduling and transportation coordination, and partnerships with state and local organizations, especially related to community-specific events, like vaccination clinics/events. Examples include:

• In Indiana, the state is tracking COVID-19 vaccinations by plan, geographic location, and demographics including race and ethnicity to help guide targeted MCO outreach.
• In Iowa, Amerigroup has been strategically redirecting traditional community relations giveaway items as part of community vaccination clinic efforts. For example, Amerigroup distributed 300 coffee shop gift cards (in the amount of $5) to college students in Iowa City to promote participation in a vaccination clinic.
• In Michigan, MCOs are employing a variety of strategies to increase COVID-19 vaccinations including member and provider incentives, using CHW workforce to provide education and outreach to address vaccine hesitancy, and partnering with community-based organizations to provide vaccines where people can easily access them.
• In Pennsylvania, MCOs have performed analysis to identify members who were at high risk for complications from COVID-19 and conducted outreach to those members to encourage vaccination. The managed care long-term services and supports (MLTSS) MCOs also coordinated to establish vaccination clinics specifically dedicated to serving their membership through partnerships with large pharmacies.
• In Utah, the state shares information with Medicaid MCOs regarding the immunization status of enrollees on a monthly basis. MCOs conduct member outreach, coordinate with PCPs, and offer incentives to enrollees (e.g., gift cards).
• In Washington, MCOs are tracking COVD-19 vaccine data within their enrollment and performing targeted outreach to members.

Although not specifically asked, several states also discussed incentives in place for MCOs to increase COVID-19 vaccination rates. For example:

• In Florida, the state Medicaid agency incentivized managed care plans to work to increase vaccination uptake. For plans that achieved a greater than 50% first dose vaccination rate for members 50 years or older by August 31, 2021, the plan accrued a dollar amount per enrollee that can be used to offset any liquidated damages assessed for calendar year (CY) 2020.³⁴
• Hawaii added an MCO P4P process measure for CY 2021 to focus MCOs on increasing COVID-19 vaccine uptake within the Medicaid population.
• Louisiana Medicaid implemented COVID-19 vaccination administration MCO incentive payments to encourage MCOs to increase vaccination rates. The state is leveraging a pre-existing managed care incentive payment program which allows for incentive payments above the capitation rate if performance targets are met. The state indicates MCOs that achieve targets and receive incentive payments could then use these funds to create member and/or provider vaccination incentives. The state is leveraging MCO performance improvement project (PIP) reporting structures that are already in place to monitor MCO performance on vaccine administration.